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CITY OF ORONO <br /> • BUILDING PERMIT APPLICATION <br /> r� FOR NEW STRUCTURES OR ADDITIONS <br /> OA, Mailing Address: Permit number: oT,0/.S-400) 8 7 <br /> r VO PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: 7 <br /> Street Address:' Received by: _ /-;I <br /> ff <br /> 5� 2750 Kelley Parkway , Plan review fee: `�IF)• Y,7 <br /> Orono,MN 55356 + 15 <br /> `gkES H4 (�? � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 121675 PI <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Dq No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I FORMATIO -7' <br /> Name: J! gl:44 / r f 0 v%cic <br /> State License# Expiration Date: 3 <br /> Phone: cell office - $&1-0 <br /> Mailing Address: Jos City: ZIP: 5;V--z,3 <br /> Contact Person: , s Appli _nt is: ontractor / Homeowner (circle One) <br /> Email and/or Fax: r V Gsn <br /> PROPERTY OWNER INFORMATION- ,` '` <br /> Name: 70��. r,e�yQ.�4Sa kel6i <br /> Phone(day): -46 0-2it b <br /> Address: S olk IgCity: nth ZIP: <br /> Email and/or Fax p <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Descri tion ofproject: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ElNew Construction Single Family with D5Residence <br /> ❑Addition attached garage ❑Garage/Accessory Bldg. ❑Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑Deck <br /> Relocation r detached garage ❑Office/Commercial ❑Private Sewer <br /> Other:(specify) o ❑Multiple Family/Condo ❑Warehouse <br /> ef,tLI El Public El Storage El Public Water <br /> **Any earth movement also require ❑Commercial ❑Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑Other:(specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehah r ek.or <br /> 4 <br /> $ Z <br /> Estimated Construction Valuation (excluding land) S,pyD <br />